Bariatric surgeries produce weight loss through two approaches:
- Creating a smaller stomach. As a result a person will feel full or satisfied with less food and is not able to eat as much food as before.
- Rerouting the food around a portion of the small intestine that normally helps break down the food. As a result, your body will not absorb all the calories in the food you eat.
Gastric bypass (also called Roux-en-Y Gastric Bypass) creates a smaller stomach but also reroutes or bypasses a portion of the small intestine. As a result, greater weight-loss is achieved then seen with procedures that only create a smaller stomach.
These 3 surgeries above are almost always done through 5 - 6 small cuts in your belly. A camera is placed in your belly to allow the surgeon to see. This type of surgery is called laparoscopy.
Biliopancreatic diversion with a duodenal switch. BPD surgery is more complex than other weight-loss surgeries and is done much less often -- usually only for severe, morbid obesity. The surgeon removes a large portion of your stomach and re-routes where the food you eat goes, so it does not pass through most of your small intestine, where food is normally absorbed.
The care of patients undergoing bariatric surgery, before and after surgery, requires specialized expertise and facilities. Studies have shown that the likelihood of complications is significantly associated with the experience of the surgeon and staff.
Benefits of Bariatric Surgery
Patients must still develop a healthy lifestyle and be calorie conscious after weight-loss surgery. Follow-up must be lifelong. Those who are able to change their lifestyle often can expect to lose 30 to 50% of their excess weight, depending on the procedure.
Bariatric surgery can reduce the risk of disease in people who have severe obesity. These risks include diabetes, high blood pressure, heart disease, stroke, obstructive sleep apnea, arthritis, and some cancers.
Successful weight loss after surgery can also lead to improvement in those who already have these conditions.
Weighing less should also make it much easier for you to move around and do your everyday activities.
Weight-loss surgery alone is not a solution to losing weight. It can train you to eat less, but you still have to do much of the work. To lose weight and avoid complications from the procedure, you will need to follow the exercise and eating guidelines that your doctor and dietitian gave you.
Candidates for Bariatric Surgery
Surgery may be used for individuals who have severe obesity for 5 years or more and have not responded to other weight-loss therapies, such as diet, exercise, or medications.
Body mass index (BMI) is the most common measure of obesity. BMI measures your weight in relation to your height.
Doctors often use the following BMI measures to identify patients who may be most likely to benefit from weight-loss surgery:
- A BMI of 40 or greater. This usually means men are 100 pounds and women are 80 pounds over their ideal weight.
- A BMI of 35 or greater along with a serious medical condition related to obesity. These are called comorbidities, and include such conditions as:
- Diabetes (high blood sugar)
- High blood pressure
- Osteoarthritis (severe)
- Sleep apnea (symptoms such as sleepiness during the day and loud snoring, gasping, and interrupted breathing during sleep)
- Heart disease (personal or family history)
Some experts are now even encouraging weight-loss surgery for most patients with a BMI of 30 or greater and diabetes. Studies have shown that bariatric surgery is a clinically beneficial and cost-effective treatment for certain obese patients with type 2 diabetes. Weight-loss surgery appears to produce better glucose control than medical therapy alone.
Your doctor must also consider medical problems that could make surgery more risky for you. These include:
- Liver or kidney disease
- Diseases of the stomach or small intestine
- Alcohol or substance abuse
- Current smoking
- Poorly controlled psychiatric or emotional problems
Patients with binge eating disorder should be identified before surgery and treated. A full evaluation, including a psychological evaluation, should be performed on all candidates for surgery.
Depending on insurance coverage and which procedure is performed, the cost of bariatric surgery may be up to $35,000. More and more insurance companies are willing to pay for the surgeries for patients who meet the above criteria.
Patient considering bariatric surgery should be well-informed regarding the procedure, its efficacy, side effects, and complications. They should also understand the following:
- Lifestyle and behavioral changes will still be needed after surgery, including:
- The continued need to focus on weight
- The need to chew food well
- The need for dietary restrictions
- The need for vitamin and mineral supplementation
- Patients will be unable to eat large meals.
- Surgery may not be successful in achieving significant weight loss.
Is weight-loss surgery safe for teens?
- Studies about adolescents who have had bariatric surgery suggest that these operations are at least as safe for adolescents as they are for adults. But not enough teenagers have been followed after their weight-loss surgery to know if there are any long-term effects on their future growth or development.
- Teenagers' bodies are still changing and developing. Because of the quick weight loss after surgery, they will need to be careful to get all of the nutrients and vitamins their bodies require.
- Because gastric bypass surgery changes the way some nutrients are absorbed, teens who have weight-loss surgery will need to take certain vitamins and minerals for the rest of their life.
Laparoscopic gastric banding
In laparoscopic gastric banding, the surgeon places a band around the upper part of the stomach to create a small pouch to hold food. After surgery, the doctor can adjust the band to make food pass more slowly or quickly through your digestive system. The band around your stomach is filled with saline (saltwater). It is connected to a container (access port) that is placed under your skin in your upper belly. Your surgeon can make the band tighter or looser by increasing or decreasing the amount of saline in the band. To do this, your surgeon will insert a needle through your skin into the access port.
Most people go home the same day of surgery. Some will stay one night in the hospital. Most people take 1 week off of work.
The average weight loss is about one-third to one-half of the extra weight you are carrying. This may be enough for many patients. The weight will usually come off more slowly than with gastric bypass. You should keep losing weight for up to 3 years.
The band is removable, if necessary. Studies to date indicate that the intestinal tract returns to normal afterward. Studies, including those done in the elderly, have reported significant weight loss and improved quality of life with the procedure.
In gastric bypass, the stomach is divided with staples into two parts. The first part is very small, about the size of a golf ball. This small stomach is called the pouch. The second part of the stomach is much bigger, but food cannot go into it.
The small intestine is connected to the small pouch, which re-routes food around the big part of the stomach. The pouch can only hold a small amount of food, so if you eat too much or too fast you will throw up. Also, your body will not absorb all the calories in the food you eat.
Most people stay in the hospital for 2 days after open surgery. Patients may have a drain (tube) coming out of the stomach, which will drain fluids that build up after surgery. The drain tube is usually taken out about 7 - 10 days after surgery.
People may need to take time off from work for 3 - 4 weeks. However, if the work does not involve too much physical activity, they may be able to return to work sooner.
Total weight loss after bypass surgery is usually greater than after gastric banding.
Click the icon to see an image of gastric bypass surgery.
Vertical Sleeve Gastrectomy (Gastric Sleeve)
This surgery has most often been done on patients who are too heavy to safely have other types of weight-loss surgery. Some patients who have this surgery may need a second weight-loss surgery at some time in the future.
In the gastric sleeve surgery, a large portion of the stomach is removed. The new, smaller stomach is about the size of a banana. It limits the amount of food a person can eat by making them feel full after eating only small amounts.
Most people can go home 2 days after the surgery. Patients should be able to drink clear liquids on the day after surgery, and eat a puréed diet by the time they go home.
The final weight loss may not be as large as with gastric bypass. However, it may be enough for many patients. Because vertical sleeve gastrectomy is a newer procedure, there is less data about the long-term benefits and risks. Patients should consult with their doctor about which procedure is best for them.
Weight will usually come off more slowly after gastric sleeve surgery than after gastric bypass. Patients should keep losing weight for up to 2 - 3 years.
Side Effects and Complications
Risks common to all weight-loss surgeries are:
- Gallstones and gallbladder attacks -- these occur more often from rapid weight loss.
- Gastritis (inflamed stomach lining), heartburn, or stomach ulcers.
- Injury to your stomach, intestines, or other organs during surgery.
- Poor nutrition -- you will eat less food after surgery, and your body will not absorb all the calories, protein, vitamins, and minerals from the food you eat.
- Scarring inside your belly -- this could lead to a bowel obstruction (blockage) in the future.
- Vomiting -- from eating more than the stomach pouch can hold.
These problems with a gastric band or access port may occur:
- The gastric band may slip partly out of place.
- The gastric band may erode into the wall of the stomach.
- The band may cause heartburn or reflux symptoms.
- The port or tubing may break or leak. Fixing this problem would require a minor operation.
These problems may occur after gastric bypass:
- A leak can occur from any of the staple lines or from where the intestine is re-connected. If a leak occurs you will most likely need surgery to repair the leak. The risk of a leak is about 1%.
- The opening between the stomach pouch and your small intestine may get narrower. This is called a stricture. This can be treated by placing a scope down the patient's throat and using a balloon to stretch the opening bigger. Surgery is rarely needed to fix this problem.
- Open surgery may lead to an incisional hernia. An incisional hernia is a bulging of tissue through the incision.
- Anemia -- from low iron or vitamin B12 levels.
- Dumping syndrome -- this is when the contents in the stomach move through the small intestine quickly. It causes discomfort.
- Kidney stones
- Thinning of the bones (osteoporosis) -- due to the body absorbing less vitamin D and calcium.
- Patients who do not take enough protein after surgery can become malnourished.
After vertical sleeve gastrectomy, stomach contents may leak from where the remaining parts of the stomach are stapled together. Patients may need another operation to repair this problem if it occurs.
Care after Bariatric Procedures
Most people stay in the hospital for a few days after gastric bypass surgery. Patients are discharged when they can:
- Eat liquid or pureed food without vomiting.
- Move without too much discomfort.
- No longer need pain medication given by injection.
Patients continue to eat a liquid or soft diet for several weeks after the surgery. In patients receiving a pouch procedure, the pouch eventually expands to about one cup of chewed food (a normal stomach can hold up to one quart).
Follow-up appointments are essential to determine if nutritional supplements, such as iron, calcium, vitamin B12, or other nutrients, are needed. Supplements, such as a multivitamin with minerals, may be prescribed.
Patients should eat small meals (usually six) throughout the day, rather than large meals that the stomach can no longer handle.
The new stomach probably won't be able to handle both solid food and fluids at the same time. Patients should separate fluid and food intake by at least 30 minutes and only sip what they are drinking.
After surgery, tolerance of fat, alcohol, or sugar decreases. Patients should reduce their fat intake, especially:
- Deep-fried foods
- Fast-food meals
- High-fat foods
- High-sugar foods, such as cakes, cookies, and candy
Exercise and the support of others (for example, joining a support group with people who have undergone weight-loss surgery) are extremely important in achieving and maintaining weight loss after bariatric surgery.
Exercising can usually resume 6 weeks after the operation. Even sooner than that, most patients will be able to take short walks at a comfortable pace, after consulting with their doctor.